APPLICATION FOR FINAL CLOSURE OF GENERAL PROVIDENT FUND ACCOUNT

(Please ensure that all the relevant particulars are given along with certificates, where necessary to avoid delay in settlement of the claim)

1. / Name of the Subscriber
(in Block letters) / :
2. / Designation and Basic Pay / :
3. / General Provident Fund Account No. with Departmental suffix / :
4. / Date of Birth / :
5. / Office to which attached / :
6. / Residential Address after retirement / :
7. / Event necessitating closure of Account
A) / Retirement Date / :
B) / Resignation/Voluntary
Retirement Date
(attach a copy of the orders) / :
C) / Dismissal/Removal/Compulsory
Retirement/Invalidation Date / :
i)  Have you preferred on appeal
ii)  If yes, date of its disposal/ withdrawal
iii)  If no, date of expiry if appeal time
iv)  If no appeal has been preferred given an undertaking that no appeal will be preferred in future / :
:
:
: I hereby undertake that no appeal shall be preferred by me against by Dismissal/Removal/Compulsory retirement/Invalidation (Cancel whichever is not applicable)
D) / Death Date
i)  Has the subscriber filed any nomination?
ii)  If no or if the nomination has been rendered null and void who are the surviving family members on the date of death of the subscriber / :
Name Relationship with the
Subscriber / Age Marital Status
(Enclose a Legal Heirship Certificate) / :
iii)  Did the nominee die after the subscriber but before receiving payment (vide note 3 under Rule 30(ii)
iv)  If there is no nomination and if the subscriber has left no family to whom should the money be paid? / :

(Enclose letter of probate or succession Certificate)

E) / TRANSFER OF BALANCE
i)  Date of absorption
ii)  Is absorption on permanent basis?
iii)  Is absorption without break in service?
iv)  If no to (iii) is break limited to the joining time allowed on transfer
v)  If the absorption with the approval of State Government
vi)  Accounts Officer to whom the balance is to be transferred

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8. Names and address of officers served during this last 3 years

Name of the Officer Address Period Designation

------

9. Particulars of Last Fund deductions:

Pay for / GPF Subs. / Recovery refund / Total Gross amount of bill / Net Amount of bill / Date of Encashment / Place of payment / Head of Account / Token No. and Date

10. Details of advances/withdrawals in the last 12 months prior to stoppage of subscription to General Provident Fund

------Name of withdrawal Amount Date and Place of Token No.

payment and Date

Temporary Advances

Part Final withdrawal

Life Insurance of Policy

11. Religion of the Subscriber

12. Office/Treasury/Sub-Treasury at which

GPF payment is desired

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13. If you are a self-drawing officer or you desire payment on the place of last

duty, enclose the following

i)  Personal marks of identification

ii)  Specimen Signature

Left/Right hand thumb and figures Impression

14. I hereby undertake to refund any excess payment arising out of clerical errors

in the settlement of GPF claim

Station :

Date :

Signature of Claimant

(with name in Block letters)

FOR USE BY HEAD OF OFFICE/DEPARTMENT

Certified that all the particulars furnished above have been fully verified with reference to office records and are found correct.

Certified that no advance/withdrawal from General Provident Fund was granted during the last 12 months except those detailed in item (10) above

Station :

Date

Signature of Head of Office/

Head of Department